This section presents the factors that contribute to specific
nutrition conditions or situations, and describes the individuals who are more
or less likely to be nutritionally vulnerable. In the first three sections it
sets out to answer the following questions:

Who are the
overweight or obese individuals?

Who is more likely to have a
diet that is inadequate in micronutrients?

Who is more likely to be
consuming a diet that lacks diversity?

The answers to these questions can provide valuable
information for programme planners and decision-makers in their efforts to
design better-targeted programmes and formulate appropriate policies. Multiple
regression analysis was used to answer the questions, so the explanatory factors
that emerge as predictors or "descriptors" of the nutrition condition are those
that are significant after controlling for all other variables.

The last two sections of the chapter examine economic and
demographic vulnerability, and ask the following questions:

How do poorer
households differ from wealthier households in nutritional, health and
socio-economic terms?

Are households where there are
only men or only women more nutritionally vulnerable than other
households?

Are female-headed households
more nutritionally vulnerable than those headed by men?

Are older people more
nutritionally vulnerable than younger people? If so, how do their diets and
socio-economic conditions differ from those of younger people?

Again, answers to these questions should provide
important information for decision-makers.

Body mass index (BMI) was used as an indicator of overweight
and obesity. High BMI rather than low BMI is the primary nutritional concern in
Barbados (see the subsection on Nutritional status in Chapter 3), both because
of the link between obesity and mortality and because of its established link to
CNCDs such as diabetes, hypertension, coronary heart diseases and certain
cancers, as well as to the increased health care costs associated with the
management of these and related complications.

The multiple regression analysis found that 24.7 percent of
the variability in BMI was explained by factors that entered the analysis. The
following factors were significantly associated with high BMI, i.e. with
overweight and obesity:

Lower
educational attainment. In general, Barbados enjoys a high level of
literacy and educational attainment, however the analysis identified those who
completed only primary school as being more likely to be overweight (even after
controlling for age).

Employment.
Those in employment were more likely to have a high BMI than those not in
employment. Information on income was unfortunately not available for a large
proportion of the sample. As an alternative, the analysis included information
on whether the individual was employed and the nature of that employment. It is
important to state that the "unemployed" included students, housewives and
retired people, in addition to those who were genuinely unemployed.

Lower food
expenditure. Food expenditure information was collected in six
categories rather than as actual food expenditure. It was therefore not possible
to calculate per capita food expenditure. However, even after controlling for
household size, the analysis found that lower food expenditure was significantly
associated with higher BMI.

Increasing age.
The relationship between age and BMI is not linear (see Figures 2 and 3). The
prevalence of overweight and obesity increases with age until about 65 years,
when it starts to fall.

Gender.
Barbadian women are more likely to be overweight or obese than Barbadian men.
The prevalence of overweight and obesity (BMI > 25 kg/m2) was
nearly 64 percent among women and 56 percent among men.

Desire for weight
change. Respondents with a high BMI were more likely to want to change
their nutritional status. This finding shows that a weight reduction or healthy
lifestyle campaign could be positively received by those who need it
most.

Hypertension.
Not surprisingly, overweight and obese individuals were more likely to be
suffering from diagnosed high blood pressure.

Dietary
diversity. Overweight and obese respondents were more likely to have a
low dietary diversity score; in other words, these individuals were consuming a
diet that not only provided more energy than they needed (hence the high BMI),
but was also more monotonous.

Determinants of micronutrient
adequacy

Using the micronutrient adequacy score as the indicator,
multiple regression analysis found that 25 percent of the variability in the
score was explained by the following factors, after controlling for all other
relevant factors. Poorer micronutrient adequacy was associated with:

household size -
larger households were more likely to have a lower score;

lower food
expenditure;

men in male-only households,
compared with men in households composed of both sexes;

gender - women were more
likely than men to have poor scores;

not dieting - this factor
covered a range of diets, including weight-reducing diets, low-fat,
low-cholesterol or low-salt diets. This finding could suggest that respondents
with poorer micronutrient adequacy scores were generally less concerned about
healthy lifestyles, as supported by the following dietary factors;

Determinants of dietary
diversity

Using the dietary diversity score as the indicator, multiple
regression analysis found that 13.2 percent of the variability in the dietary
diversity score was explained by the following, after controlling for all other
relevant factors:

Lower food
expenditure.

Not growing own food -
respondents from households engaged in food production activities were more
likely to benefit from a diverse diet. This is an important finding because it
justifies past efforts to encourage home food production. However, further
efforts to increase home food production are unlikely to meet with much success,
and other strategies to improve the Barbadian diet should also be considered. It
is also important to bear in mind the list of constraints that respondents
identified as affecting their engagement in, or increasing of, home food
production activities. The most important of these was insufficient access to
land (see subsection on Food production in Chapter 3).

Households with only male or
only female members were more likely to have poor dietary diversity scores than
households with both male and female members. In the case of female-only
households, this may be a reflection of poverty (see the following two sections
on Poverty profile and Older people). Male-only households were not poorer than
households with both sexes, so their low dietary diversity may reflect a poorer
ability (or willingness) to prepare food.

Individuals diagnosed with
diabetes were more likely to have poorer dietary diversity. This may be a
reflection of the diabetic diet, and nutritionists should perhaps seek ways of
improving the diversity of this diabetic. Poorer diversity was also associated
with a higher BMI (overweight and obesity, as indicated in the previous section
on Determinants of overweight and obesity).

Poorer diversity was
associated with lower dietary and micronutrient supplement usage, as well as
with the unhealthy practice of adding oil or butter to gravy. In general this
indicates a lack of concern for a healthy lifestyle, or perhaps
poverty.

Respondents with lower
diversity scores were also more likely to have lower energy intakes. This may
seem to contradict the relationship between diversity and obesity. However,
obesity is not simply a result of high energy intakes, but is also an outcome of
a low level of physical activity.[18]

Poorer micronutrient adequacy
scores were associated with poorer diversity, a finding that re-emphasizes the
importance of a diverse diet.

Most Barbadians enjoy a high standard of living. Nonetheless,
the results of the regression analyses suggested that economic factors may
influence food and nutrient intakes and health status. The study therefore
examined respondents in the following categories to see whether they differed
significantly from other respondents, in socio-economic, demographic, health and
nutritional terms:

More than a quarter of the sample (25.6 percent of men and
25.3 percent of women) lived in single-sex households. Men and women in
single-sex households were compared with their counterparts in households
comprising both sexes. Women in single-sex households were more likely
to:

A high proportion of Barbadian households are headed by women:
44.6 percent. The survey also found that 23.6 percent of men and 58.9 percent of
women lived in households headed by women. It found that these households had
significantly lower median incomes than households headed by men (B$1 200 per
month, compared with B$2 000), and that a higher proportion of them fell below
the UNDP poverty line (19.8 percent, compared with 5.8 percent).

The survey found the following two differences in methods of
food acquisition between male- and female-headed households:

Households headed
by women were significantly less likely to grow food crops.

They were significantly more
likely to purchase fruits and vegetables from wayside vendors.

Female-headed households were also more likely to engage in
the healthy practice of removing the skin and fat from poultry during food
preparation.

There were significant differences between the mean ages of
men and of women dwelling in female- and male-headed households (Table
4.1):

Men in
female-headed households were younger than men in male-headed
households.

Women in female-headed
households were older than women in male-headed households.

Table 4.1 Mean ages of respondents living in female-and
male-headed households, by sex

Sex

Mean age (SD) in years

Female-headed households

Male-headed households

Men

39 (17)

51 (17)

Women

52 (19)

46 (17)

These age differences made it necessary to examine differences
between the inhabitants of male- and female-headed households in two separate
age groups (< 45 years and ³ 45 years). Few
differences emerged from these analyses, despite the findings regarding
household incomes already noted. The following were the significant
differences:

Younger men
(< 45 years) in female-headed households, compared with those in
male-headed households, were more likely to:

- be unemployed;- have lower
BMI;

and less likely to:

- suffer from high blood pressure;-
consume alcohol.

Younger women (< 45
years) in female-headed households, compared with those in male-headed
households, were more likely to consume meals outside the home. This may be
because women in female-headed households are more likely to work outside
the home.

Older men (³ 45 years) in female-headed households, compared
with those in male-headed households, were more likely to: -have high protein
intakes; -have high dietary diversity scores.

Older women (³ 45 years) in female-headed households, compared
with those in male-headed households, were more likely to:

In summary, respondents living in female-headed households
appear to be no more nutritionally vulnerable than their counterparts in
male-headed households, despite lower incomes. Arguably, the higher dietary
diversity scores, at least among older men and women in female-headed
households, indicate better diets.

Older people

Recent demographic trends in the Caribbean, as elsewhere in
the world, indicate a major increase in the proportion of the population to be
made up of older people. It is forecast that this proportion will reach or
exceed 10 percent by 2025 in most Caribbean countries.

In Barbados, this figure has already been exceeded: in 1997,
12 percent of the population (32 730 men and women) were aged 60 years and over,
and this proportion is expected to rise to 23.2 percent (67 037 people) by 2025,
with 62 percent of these people being at least 75 years of age. In the survey
sample, 20.5 percent of men and 22.6 percent of women were aged 65 years or
over.

Older people face a range of risk factors that make them
especially vulnerable to poor nutrition. These include the following:

Economic
factors. Many older people rely on limited pensions, savings and gifts
from relatives, which are often inadequate to meet their needs or the rising
cost of living.

Social
isolation. Emigration, the breakdown of the extended family and the
death of younger adults from AIDS leaves many older people without essential
social and support networks.

Physical and mental
disabilities and disorders. These include impaired mobility and poor
functional ability (often related to bone, joint and muscle disorders such as
arthritis), poor dentition, vision and hearing, and senile dementia.

Poor health.
Older adults are those most likely to suffer from CNCDs, such as diabetes,
hypertension and cardiovascular disorders. Furthermore, in many countries,
access to health care is limited because of poverty, poor mobility and a health
system that is geared more to meeting the needs of infants, children and younger
adults. In Barbados, however, older people enjoy ready access to health
services, and utilization is high.

Physiological
changes. Age-related changes in taste, smell, appetite and
gastrointestinal function can limit or substantially alter food preferences and
consumption patterns. There are also age-related changes in nutritional
requirements, which frequently go unrecognized by older people and their
families. In addition, older people are often on long-term medication, which can
have an impact on taste, appetite and nutrient needs and absorption.

Because a substantial proportion (22 percent, N = 352) of the
sample comprised older people (³ 65 years), it was
possible to analyse their food and nutrition situation, and related
socio-economic and health factors. The analysis included:

comparisons with
United Kingdom (HMSO 1990 and 1998) and United States data (CDC, 1988-1994):
dietary intakes (UK), and BMI (UK and USA);

a comparison of the health and
nutrition of older adults (³ 65 years) with those
of younger adults (< 65 years);

a comparison of men and women
aged ³ 65 years;

a comparison of older people
living alone with those not living alone.

COMPARISON WITH UNITED STATES AND UNITED KINGDOM
DATA

Table 3.10 provides comparative data from Jamaica, the United
Kingdom and the United States. The mean BMI of older Barbadian men is lower than
the mean BMIs of men in either the United Kingdom or the United States.
Barbadian women, have a mean BMI that is close to those of women in the United
Kingdom and of white United States women, but lower than that of black United
States women; it is also higher than the mean BMI of older, urban Jamaican
women.[22]

Table 4.2 compares dietary intake data from the Barbados
survey with similar data from the United Kingdom. With the exception of fats,
calcium and zinc, the dietary intakes of all nutrients are substantially higher
among older Barbadian men and women than among their United Kingdom
counterparts. Especially noteworthy are the substantially higher intakes of all
micronutrients, except calcium and zinc. Clearly older Barbadians fare better in
the comparison than younger Barbadians, whose intakes of all micronutrients
except iron and vitamin C were lower than those of their United Kingdom
counterparts.

Table 4.2 Comparison of Barbados and United Kingdom dietary
intakes: median intakes of older men and women, aged ³ 65 years

Nutrients

Men

Women

Barbados

UK

Barbados

UK

18-64

16-64

18-64

16-64

Energy (kcal)

2 026

1 915

1 720

1 414

Protein (g)

84.8

71.4

71.5

55.9

Carbohydrate (g)

270

230

247

175

Fats (g)

51.0

72.8

42.3

57.5

Calcium (mg)

575

824

505

655

Iron (mg)

14.9

10.5

12.3

8.3

Zinc (mg)

7.2

8.5

6.1

6.5

Vitamin A (RE)

963

387

729

422

Thiamin (mg)

1.53

0.76

1.27

0.83

Riboflavin (mg)

1.54

0.87

1.2

0.95

Niacin (mg)

23.2

16.5

18.0

17.2

Folate (µg)

208

138

196

137

Vitamin C (mg) % of energy from

74.8

30.3

70.1

35.1

Protein

16.6%

15.7%

16.2%

16.1%

Carbohydrates

58.8%

48.4%

59.3%

47.4%

Fats

24.2%

35.6%

25.0%

36.3%

COMPARISON WITH YOUNGER ADULTS

In general, older people in Barbados appear to enjoy good
nutritional status and dietary intakes (see Tables 3.10, 3.17 and 3.18).
Although the prevalence of undernutrition increases slightly after the age of 64
years, overweight and obesity decline (see Figures 2 and 3). Older people's
nutrient intakes are adequate in relation to their RDAs for all nutrients except
zinc (see comments on zinc intakes in the sections on Recommendations for future
surveys: difficulties encountered and limitations of the survey in Chapter 2,
and Nutrient intakes in Chapter 3) and calcium, the latter especially in the
case of women.

Analysis to compare the health and nutrition of older and
younger Barbadians showed positive and negative features from the perspective of
older people. On the positive side, older adults were significantly
more likely to:

remove skin and fat from
poultry and meat (one of the "healthy" practices investigated).

SUMMARY

In Barbados, the growth of the older population has been
accompanied by the development of a number of programmes, both public and
private, to meet the needs of older people. A pension provides the main, often
the sole, income during retirement. Facilities for older adults include
government institutions (eight polyclinics and three satellite clinics in a
government hospital, as well as three district hospitals; a residential home for
older adults, a hostel and an activity centre), and private or non-governmental
institutions (more than 40 private nursing and residential care homes, one
day-care centre, a meals centre, and a senior citizens' village complex). In
addition, the government's Alternative Care for the Elderly programme purchases
space from private nursing homes for the care of ambulant older
people.

Fifty percent of admissions to government institutions are the
result of chronic medical disorders, lack of social support, poor housing,
poverty, and lack of adequate home care. A high percentage of these people die
soon after admission: for the period 2000 to 2002, 47.5 percent of older people
admitted to a government institution died within the first six months of
admission. The reasons for this include apathy, withdrawal and inappropriate
management of malnutrition.

While commendable progress has been made to address these
issues, including the establishment of a non-governmental organization (NGO),
the Barbados Association of Retired Persons, and the National Committee on
Ageing, the following areas need attention:

improving the
quantity and quality of home and community-based care to permit older people to
remain in their homes and communities if they wish;

supporting families in their
efforts to provide better care for older relatives;

enacting legislation that
addresses the abuse and neglect of older people, the deprivation of property and
financial assets, and all forms of age discrimination;

providing better nutrition
support and guidance for older people, and making available nutrition
information for older people, their care givers and health professionals. The
survey results point to specific nutrition issues that need to be addressed:
dietary diversity, improving the dietary management of CNCDs, and increasing the
consumption of fresh fruits and vegetables;

reaching and supporting older
people living alone;

recognizing the rights,
contributions and dignity of older people.

While the survey results point to a generally good nutritional
status and dietary intake for older people, there are trends indicating that
younger adults may be engaging in dietary practices that will lead to a higher
proportion of nutritional problems in the future.

[16] Many factors are
interrelated. Thus, for example, educational attainment influences the type of
employment that the individual is engaged in, and hence his/her income. Multiple
regression analysis seeks to answer such questions as: Does income itself affect
the nutrition condition, regardless of educational attainment or type of
employment?[17] It should be borne in
mind that many respondents failed to answer the question on alcohol consumption;
in general information on this topic is unreliable.[18] Overweight individuals
are also more likely to underestimate or conceal their true food
intake.[19] Nearly a quarter of the
households failed to provide information on income, and so were excluded from
this analysis of a poverty profile, which may have introduced a bias. In
addition, the indicator of poverty used was income per capita, in an effort to
capture the effect of household size. This indicator makes no allowance for the
ages of household members, and may therefore incorrectly classify as
poor households with young children whose nutritional needs are
lower than those of adults. The cut-off used to define poverty is arbitrary;
that used to identify the lowest third of the income per capita range was £ B$400 per capita.[20] The rationale for
selecting this form of potential vulnerability was that, on the one hand,
female-only households are likely to be more economically deprived and, on the
other hand, male-only households are more likely to have poor food preparation
skills.[21] These activities may
actually have been carried out by the men in mixed households, rather than the
women in these households.[22] It should be noted that
the Jamaican data are from a limited survey made in 1984 (Broome, 1984). The
picture may be quite different now.